For your convenience, our intake forms are available to print from the website. Choose the intake packet that is listed for your counselor and that is for the appropriate age bracket. For example, if you are seeing Jennifer and if the
client is a child, print all forms from that section. Carefully read and complete the intake forms
IN BLACK INK
and bring them with you to your first appointment.
Please bring all pages of the forms (not just the signature pages); we will be
happy to give you copies of them if you wish. This will save a lot of time so we can make the best use of your first appointment!
Click here for
Directions to Our Office
*For couples counseling, each partner needs to complete his or her own intake packet.
(Click on the intake packet that is listed for your counselor and that is for the appropriate age bracket. )
Jennifer's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
COVID Release of Liability
Jennifer's Intake Packet for Children (Ages 6 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Jennifer's Intake Packet for Couples* Counseling
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Gottman Permission Form
Sarah's Intake Packet for Adults and Couples* (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Sarah's Intake Packet for Teens (Ages 15 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Emily’s Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Emily’s Intake Packet for Children (Ages 8 through 17)
Patient Health Questionnaire – ages 12 and up only
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
J'Nae's Intake Packet for Children and Adolescents (Ages 3 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Robyn's Intake Packet for Adults and Couples* (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Robyn's Intake Packet for Children and Adolescents (Ages 10 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Antoine's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Antoine's Intake Packet for Teens (Ages 16-17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Mary Margaret's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Mary Margaret's Intake Packet for Children and Adolescents (Ages 12 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Gabriella's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Gabriella's Intake Packet for Children and Adolescents (Ages 12 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Kelly's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
COVID Release of Liability
Teletherapy Consent Form
Kelly's Intake Packet for Children and Adolescents (Ages 7 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
COVID Release of Liability
Teletherapy Consent Form
Kervins' Intake Packet for Adults and Couples (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Kervins' Intake Packet for Adolescents (Under 18)
Patient Health Questionnaire - Ages 12 and up only
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
David's Intake Packet for Children and Adolescents (Ages 3 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
David's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Melissa's Intake Packet for Children and Adolescents (Ages 9 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Melissa's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Teletherapy Consent Form
COVID Release of Liability
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Yang's Intake Packet for Adults and Couples (Ages 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Record
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Yang's Intake Packet for Adolescents (Ages 15 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Consent to Treat Minors
Consent to Record
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Yoga Workshop Intake Packet
The Breathing Room Waiver
Professional Disclosure Statement
Notice of Privacy Practices
Patient Health Questionnaire
PHI Consent
Confidentiality Statement
Parent Counseling Group Intake Packet (One Per family)
Group Registration Form
Professional Disclosure Statement
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Confidentiality Statement
Sharing the Journey Group Intake Packet (One Per family)
Professional Disclosure Statement
Confidentiality Statement
PHI Consent
Notice of Privacy Practice
Credit Card Payment Form